ORIGINAL ARTICLE
The Relationship Between Workplace Environment and Employee Health Behaviors in a South African Workforce Tracy Kolbe-Alexander, MPH, PhD, Michael Greyling, MSc, Roseanne da Silva, BScHons, FIA, Karen Milner, MA, PhD, Deepak Patel, MD, MSc, Lauren Wyper, BSc, RD (SA), Meghan Beckowski, MPH, Estelle V. Lambert, MSc, PhD, and Ron Goetzel, PhD Objective: To determine the relationship between the availability of wellness facilities at worksites and self-reported employee health behaviors (physical activity [PA] and nutrition [NUT]). Methods: Employers (n = 71) and employees (n = 11472) participated in the South African Healthy Company Index survey. The survey included self-reported clinical measures and lifestyle behaviors. A facility score was calculated, ranging from 0 to 100. Hierarchical linear models were used to calculate the relationship between facility scores and whether employees met PA and NUT guidelines. Results: The mean total facility score was 58.5 ± 25.5. The number of facilities at each worksite accounted for 5.4% of the variance in PA among employees (r = 0.054; P = 0.036). Higher facility scores were associated with better NUT habits among employees. Conclusions: Employers providing wellness facilities are likely to have employees with better PA and NUT habits.
N
oncommunicable diseases (NCD) such as cardiovascular disease, diabetes, and hypertension account for 60% of deaths globally.1 This burden of NCDs is increasing and affects both developed and developing countries. In South Africa, NCDs account for more than a third (37%) of all deaths.2 In addition to the increasing prevalence of NCD-related morbidity and mortality, there is a concomitant increase in the prevalence of contributing risk factors including physical inactivity and obesity.3,4 The workplace has been identified as a setting that can potentially reach a large number of people simultaneously. Research conducted over the past 30 years suggests that comprehensive and evidence-based worksite health promotion programs can improve From the University of Cape Town (Dr Lambert), South Africa; the Centre for Research in Exercise (Dr Kolbe-Alexander), Physical Activity and Health, School of Human Movement Studies, University of Queensland, Brisbane, Australia; the University of Witwatersrand (Mr Greyling, Ms da Silva, and Dr Milner); Discovery Health (Dr Patel and Ms Wyper), Johannesburg, South Africa; Thomson Reuters (Ms Beckowski and Dr Goetzel), Washington, DC; Rollins School of Public Health (Dr Goetzel), Institute for Health and Productivity Studies, Emory University, Atlanta, Ga; and Truven Health Analytics, Bethesda, Md (Dr Goetzel). Discovery Health funded the South African Healthy Company Index (HCI). Ethical approval for this research study was obtained from the University of the Witwatersrand (MO91126). All data for the HCI were quality checked and analyzed by the Data Management and Statistical Analysis Company. Deepak Patel and Lauren Wyper were employed by Discovery Vitality while the Health Company Index research was being conducted; however, all the data were collected and analyzed independently of Discovery by the researchers involved in the study. All data analysis for this study was conducted by the University of Cape Town and University of Witwatersrand, and there were no restrictions in publishing the findings. The opinions expressed are the authors’ and do not necessarily represent the opinions of Thomson Reuters, Emory University, the University of the Witwatersrand, the University of Cape Town, or Discovery Health. The authors declare no conflicts of interest. Address correspondence to: Tracy Kolbe-Alexander, MPH, PhD, Centre for Research on Exercise, Physical Activity and Health, School of Human Movement Studies, Blair Dr, St Lucia, 4072, University of Queensland, Brisbane, Australia ([email protected]). C 2014 by American College of Occupational and Environmental Copyright Medicine DOI: 10.1097/JOM.0000000000000236
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employee health as well as reduce health care expenditures.5,6 A previous study conducted with South African companies reported that the employed population was at an increased risk for NCDs because workers exhibited poorer lifestyle behaviors compared with the general South African population.7 For example, nearly 70% of employees in that study did not meet the recommended 30 minutes of physical activity on at least 5 days of the week criterion established by the US Centers for Disease Control and Prevention. Furthermore, nearly half of the employees were overweight, defined as having a body mass index (BMI) greater than 24.9 kg/m2 , and nearly a quarter were smokers.7 These findings underscore the need for worksite facilities and intervention programs that aim to reduce the prevalence of risk factors among employees. Environmental and policy approaches have been shown to support healthy lifestyle behaviors at the workplace.8 These approaches have been identified as important determinants of health and lifestyle among employees at their places of work.9,10 Environmental interventions are aimed at the worksite or organizations as a whole, as a complement to individual interventions with the aim of influencing all aspects of the workplace, both individual and organizational.11 Facilities encouraging healthy nutrition, physical activity, and smoking cessation are examples of environmental interventions at worksites. In this study, we examine whether providing health-promoting facilities at the workplace is associated with improved health status among employees. We hypothesize that employees at companies that have more worksite health promotion programs and facilities are more likely to be physically active, have healthier eating habits, and be at lower risk for NCDs, compared with employees at companies with fewer worksite health promotion programs or facilities.
METHODS Study Design This was a cross-sectional study design comparing organizational facility scores with individual employee health risks and lifestyle behaviors. The organizational facility score measured the extent to which an employer provided a health-promoting environment, whereas individual employee risk and behaviors scores were related to physical activity and fruit and vegetable intake. The researchers hypothesized that higher worksite facility scores would be associated with decreased risk of NCDs and improved lifestyle behaviors among employees.
Participants and Setting The participants included companies (worksites) and their employees from various industry groups and in each of the nine South African provinces. This research was part of a larger project, the Discovery Healthy Company Index (HCI), a national initiative seeking to promote worksite wellness and to identify the healthiest companies in South Africa.12 The recruitment and registration process has been described in detail by Patel et al.12 Once companies were registered, the employers received an e-mail from the research team, confirming participation. Subsequently, the human resource managers sent their employees an e-mail informing them of the HCI study survey and JOEM r Volume 56, Number 10, October 2014
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inviting them to participate. Both employers and employees signed a consent form electronically before completing the online health assessment.12 Three e-mail reminders were sent during the 2 weeks to encourage completion of the questionnaire. Confidentiality and voluntary participation were emphasized. Employees were assured that their employers and Discovery Health would not have access to their data, as all results were encoded and collated with no personal identifiers.
Inclusion Criteria Companies with 50 or more employees were eligible to participate in the HCI to ensure a minimum level of statistical credibility.12 All employees at these companies were eligible to complete the employee-based survey.
Employer Questionnaire The manager responsible for the company’s worksite health promotion programs or the human resource manager completed the employer questionnaire online. The questionnaire composed of the following subsections: demographic information, current health promotion initiatives, on-site facilities, company health-related policies, and leadership support. The survey was largely based on the National Worksite Health Promotion Survey, which was administered by the US Department of Health and Human Services and an organizational assessment tool that was developed by Emory University for a 5-year longitudinal research study.13
Employee Questionnaire The employee questionnaire was designed using questions found on the Discovery Health Vitality health risk assessment in which employees self-reported clinical measures such as height, weight, blood pressure, and total cholesterol in addition to lifestyle behaviors including smoking status, physical activity and nutrition habits.
Workplace Environment and Employee Behaviors
TABLE 1. Description of the Various Facility Scores Type
Number of Questions
Maximum Score
20 12
100 60
4
20
3
15
Total facility score Physical activity facility score Physical activity environment score Nutrition Facility Score
facility score for each company was 100, on the basis of the response to the 20 items, which included questions on general health promotion and screening (n = 10), physical activity (n = 4), nutrition (n = 4), and smoking cessation (n = 2).
Physical Activity Facility Scores The physical activity facility score was determined on the basis of responses to four questions from the total facilities score and an additional eight questions from the questionnaire. If companies answered “yes” for a physical activity facility, they were given a score of five. A maximum score of 60 was obtained if a company responded “yes” on all 12 questions. These included items such as companysponsored sports leagues, fitness testing, on-site exercise facilities, subsidized gym membership, and walking or running groups.
Physical Activity Environment Score
Employees were categorized as being at increased risk for NCD according to the following criteria:
This score was based on the response to four questions relating to the worksite environment-enabling physical activity. These included having on-site exercise areas such as fields and trails for employees to use, stairwells that are well lit and easily marked, signage to promote use of stairs instead of elevators, and showers and change room facilities. The maximum physical activity environment score was 20.
r A BMI greater than 24.9 kg/m2 assigned a person into an over-
Nutrition Facility Score
Classification of Risk for NCD
weight category and a BMI of 30 kg/m2 placed the person into a high-risk category of obesity.14,15 r A blood pressure of more than 140/90 mm Hg and 160/95 mm Hg16 placed the individual as being at stage 1 and stage 2 hypertension, respectively. A total serum cholesterol reading of more than 5.2 mmol/L placed the individuals in the at-risk category.17 r High risk for nutrition was defined as consuming fewer than five servings of fruits and vegetables per day.18 Employees who were physically active for less than 150 minutes a week were also categorized as being at risk for NCD.19
Facilities Score A summary of the various facilities scores is presented in Table 1.
Total Facilities Score The facilities survey was modeled after the health and productivity management organizational assessment tool developed by Emory University.20 Questions probed on the availability of health improvement facilities and worksite health promotion programs related to screenings and educational programs focused on reducing risks related to physical inactivity, poor diet, and weight management. A total facilities score was based on responses to 20 questions.12 Companies were scored zero if they did not have the facility or program in place and five if they did. The maximum total
The nutrition facility score was based on worksite facilities and worksite health promotion programs, with a focus on improving nutrition. There were three nutrition-related questions used in the calculation of the HCI, which were nutrition education and counseling, weight management programs (either fully paid for or subsidized), and healthy alternatives in the canteen.
Statistical Analysis STATA software (StataCorp, College Station, TX) was used for all the analyses. Descriptive statistics, which included frequency tables, were performed for the total sample and separately for men and women. Mean, standard deviation, and standard error were calculated for all continuous variables. An analysis of variance was applied to determine whether there were any differences on selfreported physical activity and fruit and vegetable intake, with selfreported health status. As the analysis needed to reflect that the respondents were clustered within organizations and that variables were measured both at the level of the organization (facilities scores) and at the level of the individual (eg, BMI), the framework of the hierarchical linear model21 was used to analyze the data. Hierarchical linear model (also known as multilevel analysis) explicitly models the intracluster correlation and as such corrects for the lack of independence produced by the sampling procedure. Where the dependent variable was dichotomous, a multilevel equivalent of logistic regression was used.22
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RESULTS
Physical Activity and Nutrition Facilities Scores
Participant Characteristics
The sample included 71 companies and their employees (n = 11,472). Of the employees who responded to the survey, 42% were male (n = 4766) and 58% were female (n = 6706). The mean age of all the employees was 36.3 (standard deviation [SD], 9.9) years, and the men were significantly older, more physically active, and reportedly consumed fewer fruits and vegetables than the women (Table 2). The mean number of risk factors for NCD among employees was 4.2 ± 1.4, which was similar for men and women. Additional information for organizational and demographic characteristics and employee self-reported biometric risk factors can be found in Patel et al.12 About four out of the five employees had fewer than five servings of fruits and vegetables per day (81%), and a similar proportion (80%) reported participating in less than 150 minutes of moderateto-vigorous physical activity per week. Sixty percent of employees were either overweight or obese (BMI >24.9 kg/m2 ).
Self-Reported Health Status More than half of the employees described their health as either excellent (28%) or good (56%). The rest of employees described their health as fair (15%), poor (2%), or very poor (0.1%). There were significant differences in BMI for the employees according to their self-reported health status (Fig. 1a). The mean BMI was significantly lower (25.8 kg/m2 ) among those who categorized their health as excellent than among those in the good (27.2 kg/m2 ), fair (29.3 kg/m2 ), poor (31.23 kg/m2 ), and very poor categories (28.1) (P < 0.0001). Similarly, those who reported excellent health status consumed significantly more fruit and vegetable servings per day than those in the other four categories (Fig. 1b) (P < 0.0001). In addition, habitual levels of physical activity were significantly higher among those who rated their health as excellent and lowest for those in the very poor health category (Fig. 1c).
Worksite Facilities Total Facility Score The mean total facility score for all the companies was 58.5 (SD, 25.5), suggesting large variations in facilities among companies (Table 3). The most frequently reported health facility or program offered was emergency medical response training, which took place in 94% of the companies. Other services that were offered in most companies included employee assistance programs, which were predominantly counseling services (71%), health education (78%), and on-site screening (89%). Of the facilities that encouraged physical activity, company sports leagues were reported in 65% of companies. Healthy food options were available in nearly half of the worksites (47%). Only 1% of worksites offered smoking cessation programs; however, 42% provided support to employees to quit smoking.
The mean score for the subset of the physical activity questions was 35.8 (SD, 8.3), where the maximum possible score for a company was 60 (Table 3). The mean physical activity environment score was 11.1 (SD, 4.8) (Table 3) and the nutrition-related subset facility score mean was 5.8 (SD, 4.1), again suggesting variation across companies.
Relationship Between Facilities and Health Behavior There was a small, but significant association between the number of facilities at each company and employees’ habitual levels of physical activity (mean minutes per week). The overall facilities score accounted for 5.4% of the variance in physical activity behavior between companies (P = 0.036). Employees who participated in physical activity for 150 minutes or more per week were categorized as being sufficiently active on the basis of the US Surgeon General’s Report. Table 3 shows the results of the multilevel modeling statistics, comparing the mean (95% confidence interval [CI]) facility scores for employees who met and did not meet the physical activity guidelines. The program modeled the probability of not meeting the physical activity guidelines, which was classified as being inactive. The odds of an employee meeting the physical activity guidelines was 1:4.3, or for every one person meeting guidelines there were 4.3 who were insufficiently physically active, thus the probability of meeting the physical activity guidelines was 19%. The mean physical activity-related facility score was higher for organizations where employees met the physical activity guideline. For every additional physical activity-related facility available at the worksite, the odds of employees meeting the physical activity guidelines increased by 17% (odds ratio, 0.83; 95% CI, 0.74 to 0.93 per facility at each worksite) when analyses were performed on the number of facilities as opposed to the facilities score. Similarly, the odds of employees meeting the physical activity guidelines were also lower, in relation to the number of physical activity environmentrelated facilities (Table 3). Similar to physical activity, for every employee consuming five or more servings of fruits and vegetables per day, 4.5 did not, and the nutrition-related facility scores were higher for those meeting the recommendation (Fig. 2). Total facility scores showed a very small, but significant relationship with fruit and vegetable intake, with the odds of meeting guidelines only 1.01 (P = 0.007) for every additional facility. The odds increased to 1.18 for every additional nutrition-related facility added to the worksite (P = 0.005) when only considering nutrition-related facilities.
DISCUSSION This research study aimed to determine whether there was a relationship between the provision of health-promoting facilities at worksites and individual employee risk for NCDs and healthpromoting behavior. The researchers hypothesized that employees based at worksites with more health promotion facilities would have
TABLE 2. Demographic and Clinical Characteristics of Participants
Age, yrs Vitality age, yrs Body mass index, kg/m2 Fruit vegetables, servings/d Physical activity, min/wk
Total (n = 11 472) Mean (SD)
Men (n = 4 766) Mean (SD)
Women (n = 6706) Mean (SD)
P
36.38 (9.94) 40.05 (11.68) 27.17 (7.23) 3.03 (1.79) 79.25 (92.19)
37.2 (10.2) 40.8 (11.9) 27.6 (6.7) 2.87 (1.74) 100.5 (104.4)
35.8 (9.7) 39.6 (11.5) 26.9 (7.6) 3.13 (1.81) 64.2 (79.1)
0.0000 0.0000 0.0000 0.0000 0.0000
SD, standard deviation.
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Workplace Environment and Employee Behaviors
(a) Body Mass Index kg/m2
35
* *
30
*
* 25
Ve ry
Po
or
Po or
Fa ir
Ex ce l
G oo
d
le nt
20
Self-reported health status 4
Fruit and Vegetables (servings per day)
(b)
*
3
*
*
*
2
1
nt
Fa
oo
G
E
or
ir
d
lle
e xc
or
Po
ry
Po
Ve
Self-reported health status
(c) Physical Activity (minutes per week)
125 100
*
75 50
* *
25
nt
le
l ce
Ex
d
oo
G
ir
Fa
*
or
or
Po
ry
Po
Ve
Self-reported health status
FIGURE 1. Self-reported health status and body mass index (a), fruit and vegetable intake (b), and physical activity (c). *Significantly different (p < 0.05) compared with those who rated their health as excellent.
lower risk for NCDs, be more physically active, and consume more servings of fruits and vegetables per day than those based at worksites with fewer facilities. The main finding from this study was that employees at companies with a greater number of health promotion facilities were more likely to engage in healthy lifestyle behaviors, specifically meeting the physical activity guidelines and eating five or more
servings of fruits and vegetables per day. The relationship between facilities and behavior improved if the facility was specific to promoting an intended behavior. For example, the odds of employees meeting the physical activity guidelines were higher when comparing self-reported physical activity with the physical activity-related facilities and environment at the worksite. In addition, more employees were meeting the five servings of fruits and vegetables per day recommendation in those companies that had a greater number of nutrition-related health promotion programs. These findings are supported by the “North Carolina SixCounty Cardiovascular Health Survey,” in which employed adults were more likely to report being physically active if their worksites subsidized gym membership or if they were able to participate in physical activity during working hours.23 The odds of employees participating in physical activity during their leisure time were 4.1 (95% CI, 2.01; 8.40) times higher for employees whose worksites had at least three policies or programs that promoted physical activity.23 The odds of employees meeting the physical activity guidelines in this study were lower, and may be due, in part, to the different ways in which physical activity was quantified, or facilities scores were generated. We quantified physical activity as a continuous measure (on the basis of self-reported frequency, duration, and intensity of physical activity), and then categorized employees into those meeting or not meeting guidelines. Conversely, Lucove et al23 categorized physical activity as a dichotomous variable based simply on whether or not their participants reported any physical activity during their leisure or work time. Although the increased odds of 1.11 (P < 0.0002) of employees meeting the physical activity guidelines per additional facility observed in our research study might seem small, it is in line with what has been observed in previous research with worksite intervention studies.24 A review on worksite intervention studies found that interventions resulted in a median increase in physical activity of 11.1% per week, which ranged from 1.7% to 88.5%.24 This review also showed that the mean increase in fruit and vegetable intake was 0.14 fruit and vegetable servings per day with worksite interventions.24 Thus, our findings are within the ranges reported in previous studies.24,25 Furthermore, previous research has shown that return on investment can be achieved if employees’ risk is reduced by only 0.1% to 0.2% per year.26 Therefore, it seems that the health promotion programs and facilities at companies should be targeted at the specific behavior that needs to be addressed or improved. Employers that seek to encourage a particular behavior should consider developing facilities that specifically address those behaviors and not general health facilities. The most commonly reported physical activity program reported in this study was the provision of sports leagues for employees. Nevertheless, this type of program would probably only appeal to those employees who are already physically active, or have higher self-efficacy scores. Self-efficacy has been shown as an important predictor and mediator for participation in physical activity.27 Subsequently, employers should include other opportunities for physical activity that would appeal to the broader workforce. Another important finding from this research study was that certain self-reported healthy lifestyle behaviors, specifically physical activity and fruit and vegetable intake, are associated with selfreported health status. Despite the mean age of the employees being relatively young, there was a high prevalence of employees being overweight or obese, and an average of more than four risk factors per employee. Similar health and NCD risk profiles were observed in previous studies among South African employees.7 Most of the employees in this study were not meeting the US Centers for Disease Control and Prevention and American College of Sports Medicine’s guideline of 150 minutes of moderate-to-vigorous physical activity per week. Results from previous worksite-based research studies had
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TABLE 3. Worksite Facilities Scores for Physically Active (>150 min/wk) and Inactive Employees
Total facilities (out of 100) Physical activity facilities (out of 60) Physical activity environment (out of 20)
Total Mean (95% CI)
Physically Active Mean (95% CI)
Inactive Mean (95% CI)
Multilevel Model BO1; OR (95% CI)
58.4 (57.9–58.9) 35.8 (36.6–36.1) 11.1 (10.9–11.1)
59.6 (58.6–60.6) 37.9 (37.3–38.5) 11.9 (11.7–12.2)
58.1 (57.6–58.6) 35.2 (34.9–35.5) 10.8 (10.7–10.9)
−0.004; 0.99*a (0.9907–0.999)* −0.19; 0.83*a (0.74–0.93)* −0.18; 0.8*a (0.75–0.93)*
*P < 0.05. a The system modeled the probability of inactive. As such the signs of the regression coefficients are reversed and the odds ratios are inverted. CI, confidence interval; BO1, coefficient value from the Hierarchical linear model; OR, odds ratio.
and vegetable consumption were more likely to report their health status as good than those in the lower quartiles (odds ratio, 1.30; 95% CI, 1.11 to 1.53).32 Therefore, employees who perceived their health as good or excellent had reduced risk for NCDs.
Fruit and Vegetable Intake Nutrition Facility Score
7.0
Strengths and Limitations
6.5
6.0
*
is k R At
N
ot a
tR
is
k
To ta l
5.5
FIGURE 2. Nutrition facilities scores for the total group, according to fruit and vegetable intake: mean (95% CI). Represents significant differences (p < 0.05) between those ‘at risk’ compared with those ‘not at risk’. similar results, with low levels of physical activity ranging from 22% to 56% among employees.28,29 Therefore, large proportions of the employees are at increased risk of NCDs and would benefit from worksite health promotion programs. In this study, we found that self-reported health status was significantly associated with BMI, physical activity, and fruit and vegetable intake. The mean BMI was similar for employees who rated their health as fair, poor, and very poor. This might be due to a lack of understanding of what is regarded as an ideal body weight by South Africans.30 In a recent South African National Health and Nutrition Examination Survey, only a few respondents were able to identify a silhouette representing ideal body weight, compared with under- or overweight.30 Employees who perceived their health status as excellent or good were more physically active, ate a healthier diet composed of more fruits and vegetables, and had lower BMI measures than those who perceived their health as poor. Because of the current study being cross-sectional in nature, we are unable to determine whether the employees’ poor health status was a result of inactivity or being overweight. Nevertheless, the findings from this study are in line with other research.27,31,32 Bize and Plotnikoff33 reported comparable findings among employees participating in a worksite intervention program in Canada. The Canadian study also showed a statistically significant lower BMI and increased leisure time physical activity levels, with better self-reported health status.33 In addition, Pan et al31 found that men and women who reported their health as poor, fair, or good were less likely to meet physical activity recommendations than those who reported their health as excellent. Furthermore, men and women participating in the European Prospective Investigation into Cancer-Norfolk study with the highest fruit 1098
One of the main strengths of this research study is that the participants were from a range of worksites, representing a variety of sectors. In addition, both employer and employee completed the two sets of questionnaires independently of each other. As this is a cross-sectional study, we are unable to determine whether healthier people choose healthier worksites, or whether healthier worksites promote employee health. Thus, direction of causality cannot be determined on the basis of this study design. Nevertheless, the potential improvements in physical activity and fruit and vegetable intake, with the inclusion of facilities that promote these behaviors, are comparable to those observed in previous reviews of worksite intervention programs.24 Another limitation is related to participation bias where the companies that participated in the Discovery Healthy Company Index may have been more likely to be interested in benchmarking their worksite facilities programs and employee health than those of other companies. Previous research has shown that benchmarking health promotion practices in the worksite might be beneficial for those employers who wish to improve the efficacy of their programs and also to track changes over time.26 Similarly, the employees who volunteered to participate in the survey might have a better health status and lifestyle behaviors than those who did not participate, thus introducing some bias. Colkesen et al.34 reported that the employees who participated in an online health risk assessment were older, had a higher self-reported health status, and had fewer sick leave days per year than the nonparticipants. Nevertheless, there were no differences in sex, education level, and workability between the participants and nonparticipants. Therefore, the findings of this study might not be generalizable to the entire working population, but only to those who would choose to participate in a survey or health risk assessment.
SUMMARY There is a paucity of data providing evidence of the relationship between worksite cultures of health, which include programs and environmental initiatives supporting healthy behaviors, and employee health.26 The provision of worksite health promotion programs, together with self-reported health status, is significantly and positively associated with increased levels of physical activity and fruit and vegetable intake among South African employees participating in the Healthy Company Index. Although modest, these findings are encouraging and suggest the importance of creating worksite programs that promote healthy behaviors, which could play a role in improving employee health. Nevertheless, this is a crosssectional study and further research investigating the effectiveness of worksite health promotion programs is still required. Furthermore,
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cohort studies that employ a longitudinal study design will provide more insight into the role of the worksite environment and healthy lifestyle behaviors.
REFERENCES 1. Beaglehole R, Bonita R, Horton R, et al. Priority actions for the noncommunicable disease crisis. Lancet. 2011;377:1438–1447. 2. Bradshaw D, Groenewald P, Laubscher R, et al. Initial burden of disease estimates for South Africa, 2000. S Afr Med J. 2003;93:682–688. 3. King H, Aubert RE, Herman WH. Global burden of diabetes, 1995– 2025: prevalence, numerical estimates, and projections. Diabetes Care. 1998;21:1414–1431. 4. Mayosi BM, Flisher AJ, Lalloo UG, Sitas F, Tollman SM, Bradshaw D. The burden of non-communicable diseases in South Africa. Lancet. 2009;374:934–947. 5. Dishman RK, Oldenburg B, O’Neal H, Shephard RJ. Worksite physical activity interventions. Am J Prev Med. 1998;15:344–361. 6. Chapman LS, Lesch N, Baun MP. The role of health and wellness coaching in worksite health promotion. Am J Health Promot. 2007;21(suppl 1–10):iii. 7. Kolbe-Alexander TL, Buckmaster C, Nossel C, et al. Chronic disease risk factors, healthy days and medical claims in South African employees presenting for health risk screening. BMC Public Health. 2008;8:228. 8. Owen N, Humpel N, Leslie E, Bauman A, Sallis JF. Understanding environmental influences on walking: review and research agenda. Am J Prev Med. 2004;27:67–76. 9. French SA, Harnack LJ, Hannan PJ, Mitchell NR, Gerlach AF, Toomey TL. Worksite environment intervention to prevent obesity among metropolitan transit workers. Prev Med. 2010;50:180–185. 10. Shimotsu ST, French SA, Gerlach AF, Hannan PJ. Worksite environment physical activity and healthy food choices: measurement of the worksite food and physical activity environment at four metropolitan bus garages. Int J Behav Nutr Phys Act. 2007;4:17. 11. Engbers LH, van Poppel MN, Chin APMJ, van Mechelen W. Worksite health promotion programs with environmental changes: a systematic review. Am J Prev Med. 2005;29:61–70. 12. Patel D, Goetzel RZ, Beckowski M, et al. The Healthiest Company Index: a campaign to promote worksite wellness in South Africa. J Occup Environ Med. 2013;55:172–178. 13. Dejoy DM, Wilson MG, Goetzel RZ, et al. Development of the Environmental Assessment Tool (EAT) to measure organizational physical and social support for worksite obesity prevention programs. J Occup Environ Med. 2008;50:126–137. 14. Nishida C, Ko GT, Kumanyika S. Body fat distribution and noncommunicable diseases in populations: overview of the 2008 WHO Expert Consultation on Waist Circumference and Waist-Hip Ratio. Eur J Clin Nutr. 2010;64:2–5. 15. Aldana SG, Greenlaw RL, Diehl HA, et al. Effects of an intensive diet and physical activity modification program on the health risks of adults. J Am Diet Assoc. 2005;105:371–381. 16. Chobanian AV, Bakris GL, Black HR, et al. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension. 2003;42:1206–1252. 17. Goetzel RZ, Ozminkowski RJ, Bruno JA, Rutter KR, Isaac F, Wang S. The long-term impact of Johnson & Johnson’s Health & Wellness Program on employee health risks. J Occup Environ Med. 2002;44:417–424.
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18. Oude Hengel KM, Joling CI, Proper KI, Blatter BM, Bongers PM. A worksite prevention program for construction workers: design of a randomized controlled trial. BMC Public Health. 2010;10:336. 19. Garber CE, Blissmer B, Deschenes MR, et al. American College of Sports Medicine position stand. Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise. Med Sci Sports Exerc. 2011;43:1334–1359. 20. Pratt CA, Lemon SC, Fernandez ID, et al. Design characteristics of worksite environmental interventions for obesity prevention. Obesity (Silver Spring). 2007;15:2171–2180. 21. Raudenbush SBA. Hierarchical Linear Models: Applications and Data Analysis Methods, Second Edition. California: Sage; 2014. 22. Snijders TBR. Multilevel Analysis: An Introduction to Basic and Advanced Multilevel Modeling. California: Sage; 1999. 23. Lucove JC, Huston SL, Evenson KR. Workers’ perceptions about worksite policies and environments and their association with leisure-time physical activity. Am J Health Promot. 2007;21:196–200. 24. Soler RE, Leeks KD, Razi S, et al. A systematic review of selected interventions for worksite health promotion. The assessment of health risks with feedback. Am J Prev Med. 2010;38(suppl 2):S237–262. 25. Tamers SL, Beresford SA, Cheadle AD, Zheng Y, Bishop SK, Thompson B. The association between worksite social support, diet, physical activity and body mass index. Prev Med. 2011;53:53–56. 26. Aldana SG, Anderson DR, Adams TB, et al. A review of the knowledge base on healthy worksite culture. J Occup Environ Med. 2012;54:414– 419. 27. Plotnikoff RC, Pickering MA, Flaman LM, Spence JC. The role of selfefficacy on the relationship between the workplace environment and physical activity: a longitudinal mediation analysis. Health Educ Behav. 2010;37:170– 185. 28. Wang G, Pratt M, Macera CA, Zheng ZJ, Heath G. Physical activity, cardiovascular disease, and medical expenditures in U.S. adults. Ann Behav Med. 2004;28:88–94. 29. Mozumdar A, Liguori G. Occupational physical activity and the metabolic syndrome among working women: a Go Red North Dakota study. J Phys Act Health. 2011;8:321–331. 30. Shisana OL, Rehle D, Simbayi T, et al. SANHANES-1 team: The South African National Health and Nutrition Examination Survey: SANHANES-1. In: SANHANES-1. 1 edn. Cape Town, South Africa: Human Sciences Research Council; 2013. 31. Pan SY, Cameron C, Desmeules M, Morrison H, Craig CL, Jiang X. Individual, social, environmental, and physical environmental correlates with physical activity among Canadians: a cross-sectional study. BMC Public Health. 2009;9:21. 32. Myint PK, Welch AA, Bingham SA, et al. Fruit and vegetable consumption and self-reported functional health in men and women in the European Prospective Investigation into Cancer-Norfolk (EPIC-Norfolk): a population-based cross-sectional study. Public Health Nutr. 2007;10:34– 41. 33. Bize R, Plotnikoff RC. The relationship between a short measure of health status and physical activity in a workplace population. Psychol Health Med. 2009;14:53–61. 34. Colkesen EB, Kraaijenhagen RA, Frings-Dresen MH, et al. Participation in a workplace web-based health risk assessment program. Occup Med (Lond). 2011;61:586–589.
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The Relationship Between Workplace Environment and Employee Health Behaviors in a South African Workforce Tracy Kolbe-Alexander, MPH, PhD, Michael Greyling, MSc, Roseanne da Silva, BScHons, FIA, Karen Milner, MA, PhD, Deepak Patel, MD, MSc, Lauren Wyper, BSc, RD (SA), Meghan Beckowski, MPH, Estelle V. Lambert, MSc, PhD, and Ron Goetzel, PhD Objective: To determine the relationship between the availability of wellness facilities at worksites and self-reported employee health behaviors (physical activity [PA] and nutrition [NUT]). Methods: Employers (n = 71) and employees (n = 11472) participated in the South African Healthy Company Index survey. The survey included self-reported clinical measures and lifestyle behaviors. A facility score was calculated, ranging from 0 to 100. Hierarchical linear models were used to calculate the relationship between facility scores and whether employees met PA and NUT guidelines. Results: The mean total facility score was 58.5 ± 25.5. The number of facilities at each worksite accounted for 5.4% of the variance in PA among employees (r = 0.054; P = 0.036). Higher facility scores were associated with better NUT habits among employees. Conclusions: Employers providing wellness facilities are likely to have employees with better PA and NUT habits.
N
oncommunicable diseases (NCD) such as cardiovascular disease, diabetes, and hypertension account for 60% of deaths globally.1 This burden of NCDs is increasing and affects both developed and developing countries. In South Africa, NCDs account for more than a third (37%) of all deaths.2 In addition to the increasing prevalence of NCD-related morbidity and mortality, there is a concomitant increase in the prevalence of contributing risk factors including physical inactivity and obesity.3,4 The workplace has been identified as a setting that can potentially reach a large number of people simultaneously. Research conducted over the past 30 years suggests that comprehensive and evidence-based worksite health promotion programs can improve From the University of Cape Town (Dr Lambert), South Africa; the Centre for Research in Exercise (Dr Kolbe-Alexander), Physical Activity and Health, School of Human Movement Studies, University of Queensland, Brisbane, Australia; the University of Witwatersrand (Mr Greyling, Ms da Silva, and Dr Milner); Discovery Health (Dr Patel and Ms Wyper), Johannesburg, South Africa; Thomson Reuters (Ms Beckowski and Dr Goetzel), Washington, DC; Rollins School of Public Health (Dr Goetzel), Institute for Health and Productivity Studies, Emory University, Atlanta, Ga; and Truven Health Analytics, Bethesda, Md (Dr Goetzel). Discovery Health funded the South African Healthy Company Index (HCI). Ethical approval for this research study was obtained from the University of the Witwatersrand (MO91126). All data for the HCI were quality checked and analyzed by the Data Management and Statistical Analysis Company. Deepak Patel and Lauren Wyper were employed by Discovery Vitality while the Health Company Index research was being conducted; however, all the data were collected and analyzed independently of Discovery by the researchers involved in the study. All data analysis for this study was conducted by the University of Cape Town and University of Witwatersrand, and there were no restrictions in publishing the findings. The opinions expressed are the authors’ and do not necessarily represent the opinions of Thomson Reuters, Emory University, the University of the Witwatersrand, the University of Cape Town, or Discovery Health. The authors declare no conflicts of interest. Address correspondence to: Tracy Kolbe-Alexander, MPH, PhD, Centre for Research on Exercise, Physical Activity and Health, School of Human Movement Studies, Blair Dr, St Lucia, 4072, University of Queensland, Brisbane, Australia ([email protected]). C 2014 by American College of Occupational and Environmental Copyright Medicine DOI: 10.1097/JOM.0000000000000236
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employee health as well as reduce health care expenditures.5,6 A previous study conducted with South African companies reported that the employed population was at an increased risk for NCDs because workers exhibited poorer lifestyle behaviors compared with the general South African population.7 For example, nearly 70% of employees in that study did not meet the recommended 30 minutes of physical activity on at least 5 days of the week criterion established by the US Centers for Disease Control and Prevention. Furthermore, nearly half of the employees were overweight, defined as having a body mass index (BMI) greater than 24.9 kg/m2 , and nearly a quarter were smokers.7 These findings underscore the need for worksite facilities and intervention programs that aim to reduce the prevalence of risk factors among employees. Environmental and policy approaches have been shown to support healthy lifestyle behaviors at the workplace.8 These approaches have been identified as important determinants of health and lifestyle among employees at their places of work.9,10 Environmental interventions are aimed at the worksite or organizations as a whole, as a complement to individual interventions with the aim of influencing all aspects of the workplace, both individual and organizational.11 Facilities encouraging healthy nutrition, physical activity, and smoking cessation are examples of environmental interventions at worksites. In this study, we examine whether providing health-promoting facilities at the workplace is associated with improved health status among employees. We hypothesize that employees at companies that have more worksite health promotion programs and facilities are more likely to be physically active, have healthier eating habits, and be at lower risk for NCDs, compared with employees at companies with fewer worksite health promotion programs or facilities.
METHODS Study Design This was a cross-sectional study design comparing organizational facility scores with individual employee health risks and lifestyle behaviors. The organizational facility score measured the extent to which an employer provided a health-promoting environment, whereas individual employee risk and behaviors scores were related to physical activity and fruit and vegetable intake. The researchers hypothesized that higher worksite facility scores would be associated with decreased risk of NCDs and improved lifestyle behaviors among employees.
Participants and Setting The participants included companies (worksites) and their employees from various industry groups and in each of the nine South African provinces. This research was part of a larger project, the Discovery Healthy Company Index (HCI), a national initiative seeking to promote worksite wellness and to identify the healthiest companies in South Africa.12 The recruitment and registration process has been described in detail by Patel et al.12 Once companies were registered, the employers received an e-mail from the research team, confirming participation. Subsequently, the human resource managers sent their employees an e-mail informing them of the HCI study survey and JOEM r Volume 56, Number 10, October 2014
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inviting them to participate. Both employers and employees signed a consent form electronically before completing the online health assessment.12 Three e-mail reminders were sent during the 2 weeks to encourage completion of the questionnaire. Confidentiality and voluntary participation were emphasized. Employees were assured that their employers and Discovery Health would not have access to their data, as all results were encoded and collated with no personal identifiers.
Inclusion Criteria Companies with 50 or more employees were eligible to participate in the HCI to ensure a minimum level of statistical credibility.12 All employees at these companies were eligible to complete the employee-based survey.
Employer Questionnaire The manager responsible for the company’s worksite health promotion programs or the human resource manager completed the employer questionnaire online. The questionnaire composed of the following subsections: demographic information, current health promotion initiatives, on-site facilities, company health-related policies, and leadership support. The survey was largely based on the National Worksite Health Promotion Survey, which was administered by the US Department of Health and Human Services and an organizational assessment tool that was developed by Emory University for a 5-year longitudinal research study.13
Employee Questionnaire The employee questionnaire was designed using questions found on the Discovery Health Vitality health risk assessment in which employees self-reported clinical measures such as height, weight, blood pressure, and total cholesterol in addition to lifestyle behaviors including smoking status, physical activity and nutrition habits.
Workplace Environment and Employee Behaviors
TABLE 1. Description of the Various Facility Scores Type
Number of Questions
Maximum Score
20 12
100 60
4
20
3
15
Total facility score Physical activity facility score Physical activity environment score Nutrition Facility Score
facility score for each company was 100, on the basis of the response to the 20 items, which included questions on general health promotion and screening (n = 10), physical activity (n = 4), nutrition (n = 4), and smoking cessation (n = 2).
Physical Activity Facility Scores The physical activity facility score was determined on the basis of responses to four questions from the total facilities score and an additional eight questions from the questionnaire. If companies answered “yes” for a physical activity facility, they were given a score of five. A maximum score of 60 was obtained if a company responded “yes” on all 12 questions. These included items such as companysponsored sports leagues, fitness testing, on-site exercise facilities, subsidized gym membership, and walking or running groups.
Physical Activity Environment Score
Employees were categorized as being at increased risk for NCD according to the following criteria:
This score was based on the response to four questions relating to the worksite environment-enabling physical activity. These included having on-site exercise areas such as fields and trails for employees to use, stairwells that are well lit and easily marked, signage to promote use of stairs instead of elevators, and showers and change room facilities. The maximum physical activity environment score was 20.
r A BMI greater than 24.9 kg/m2 assigned a person into an over-
Nutrition Facility Score
Classification of Risk for NCD
weight category and a BMI of 30 kg/m2 placed the person into a high-risk category of obesity.14,15 r A blood pressure of more than 140/90 mm Hg and 160/95 mm Hg16 placed the individual as being at stage 1 and stage 2 hypertension, respectively. A total serum cholesterol reading of more than 5.2 mmol/L placed the individuals in the at-risk category.17 r High risk for nutrition was defined as consuming fewer than five servings of fruits and vegetables per day.18 Employees who were physically active for less than 150 minutes a week were also categorized as being at risk for NCD.19
Facilities Score A summary of the various facilities scores is presented in Table 1.
Total Facilities Score The facilities survey was modeled after the health and productivity management organizational assessment tool developed by Emory University.20 Questions probed on the availability of health improvement facilities and worksite health promotion programs related to screenings and educational programs focused on reducing risks related to physical inactivity, poor diet, and weight management. A total facilities score was based on responses to 20 questions.12 Companies were scored zero if they did not have the facility or program in place and five if they did. The maximum total
The nutrition facility score was based on worksite facilities and worksite health promotion programs, with a focus on improving nutrition. There were three nutrition-related questions used in the calculation of the HCI, which were nutrition education and counseling, weight management programs (either fully paid for or subsidized), and healthy alternatives in the canteen.
Statistical Analysis STATA software (StataCorp, College Station, TX) was used for all the analyses. Descriptive statistics, which included frequency tables, were performed for the total sample and separately for men and women. Mean, standard deviation, and standard error were calculated for all continuous variables. An analysis of variance was applied to determine whether there were any differences on selfreported physical activity and fruit and vegetable intake, with selfreported health status. As the analysis needed to reflect that the respondents were clustered within organizations and that variables were measured both at the level of the organization (facilities scores) and at the level of the individual (eg, BMI), the framework of the hierarchical linear model21 was used to analyze the data. Hierarchical linear model (also known as multilevel analysis) explicitly models the intracluster correlation and as such corrects for the lack of independence produced by the sampling procedure. Where the dependent variable was dichotomous, a multilevel equivalent of logistic regression was used.22
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RESULTS
Physical Activity and Nutrition Facilities Scores
Participant Characteristics
The sample included 71 companies and their employees (n = 11,472). Of the employees who responded to the survey, 42% were male (n = 4766) and 58% were female (n = 6706). The mean age of all the employees was 36.3 (standard deviation [SD], 9.9) years, and the men were significantly older, more physically active, and reportedly consumed fewer fruits and vegetables than the women (Table 2). The mean number of risk factors for NCD among employees was 4.2 ± 1.4, which was similar for men and women. Additional information for organizational and demographic characteristics and employee self-reported biometric risk factors can be found in Patel et al.12 About four out of the five employees had fewer than five servings of fruits and vegetables per day (81%), and a similar proportion (80%) reported participating in less than 150 minutes of moderateto-vigorous physical activity per week. Sixty percent of employees were either overweight or obese (BMI >24.9 kg/m2 ).
Self-Reported Health Status More than half of the employees described their health as either excellent (28%) or good (56%). The rest of employees described their health as fair (15%), poor (2%), or very poor (0.1%). There were significant differences in BMI for the employees according to their self-reported health status (Fig. 1a). The mean BMI was significantly lower (25.8 kg/m2 ) among those who categorized their health as excellent than among those in the good (27.2 kg/m2 ), fair (29.3 kg/m2 ), poor (31.23 kg/m2 ), and very poor categories (28.1) (P < 0.0001). Similarly, those who reported excellent health status consumed significantly more fruit and vegetable servings per day than those in the other four categories (Fig. 1b) (P < 0.0001). In addition, habitual levels of physical activity were significantly higher among those who rated their health as excellent and lowest for those in the very poor health category (Fig. 1c).
Worksite Facilities Total Facility Score The mean total facility score for all the companies was 58.5 (SD, 25.5), suggesting large variations in facilities among companies (Table 3). The most frequently reported health facility or program offered was emergency medical response training, which took place in 94% of the companies. Other services that were offered in most companies included employee assistance programs, which were predominantly counseling services (71%), health education (78%), and on-site screening (89%). Of the facilities that encouraged physical activity, company sports leagues were reported in 65% of companies. Healthy food options were available in nearly half of the worksites (47%). Only 1% of worksites offered smoking cessation programs; however, 42% provided support to employees to quit smoking.
The mean score for the subset of the physical activity questions was 35.8 (SD, 8.3), where the maximum possible score for a company was 60 (Table 3). The mean physical activity environment score was 11.1 (SD, 4.8) (Table 3) and the nutrition-related subset facility score mean was 5.8 (SD, 4.1), again suggesting variation across companies.
Relationship Between Facilities and Health Behavior There was a small, but significant association between the number of facilities at each company and employees’ habitual levels of physical activity (mean minutes per week). The overall facilities score accounted for 5.4% of the variance in physical activity behavior between companies (P = 0.036). Employees who participated in physical activity for 150 minutes or more per week were categorized as being sufficiently active on the basis of the US Surgeon General’s Report. Table 3 shows the results of the multilevel modeling statistics, comparing the mean (95% confidence interval [CI]) facility scores for employees who met and did not meet the physical activity guidelines. The program modeled the probability of not meeting the physical activity guidelines, which was classified as being inactive. The odds of an employee meeting the physical activity guidelines was 1:4.3, or for every one person meeting guidelines there were 4.3 who were insufficiently physically active, thus the probability of meeting the physical activity guidelines was 19%. The mean physical activity-related facility score was higher for organizations where employees met the physical activity guideline. For every additional physical activity-related facility available at the worksite, the odds of employees meeting the physical activity guidelines increased by 17% (odds ratio, 0.83; 95% CI, 0.74 to 0.93 per facility at each worksite) when analyses were performed on the number of facilities as opposed to the facilities score. Similarly, the odds of employees meeting the physical activity guidelines were also lower, in relation to the number of physical activity environmentrelated facilities (Table 3). Similar to physical activity, for every employee consuming five or more servings of fruits and vegetables per day, 4.5 did not, and the nutrition-related facility scores were higher for those meeting the recommendation (Fig. 2). Total facility scores showed a very small, but significant relationship with fruit and vegetable intake, with the odds of meeting guidelines only 1.01 (P = 0.007) for every additional facility. The odds increased to 1.18 for every additional nutrition-related facility added to the worksite (P = 0.005) when only considering nutrition-related facilities.
DISCUSSION This research study aimed to determine whether there was a relationship between the provision of health-promoting facilities at worksites and individual employee risk for NCDs and healthpromoting behavior. The researchers hypothesized that employees based at worksites with more health promotion facilities would have
TABLE 2. Demographic and Clinical Characteristics of Participants
Age, yrs Vitality age, yrs Body mass index, kg/m2 Fruit vegetables, servings/d Physical activity, min/wk
Total (n = 11 472) Mean (SD)
Men (n = 4 766) Mean (SD)
Women (n = 6706) Mean (SD)
P
36.38 (9.94) 40.05 (11.68) 27.17 (7.23) 3.03 (1.79) 79.25 (92.19)
37.2 (10.2) 40.8 (11.9) 27.6 (6.7) 2.87 (1.74) 100.5 (104.4)
35.8 (9.7) 39.6 (11.5) 26.9 (7.6) 3.13 (1.81) 64.2 (79.1)
0.0000 0.0000 0.0000 0.0000 0.0000
SD, standard deviation.
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(a) Body Mass Index kg/m2
35
* *
30
*
* 25
Ve ry
Po
or
Po or
Fa ir
Ex ce l
G oo
d
le nt
20
Self-reported health status 4
Fruit and Vegetables (servings per day)
(b)
*
3
*
*
*
2
1
nt
Fa
oo
G
E
or
ir
d
lle
e xc
or
Po
ry
Po
Ve
Self-reported health status
(c) Physical Activity (minutes per week)
125 100
*
75 50
* *
25
nt
le
l ce
Ex
d
oo
G
ir
Fa
*
or
or
Po
ry
Po
Ve
Self-reported health status
FIGURE 1. Self-reported health status and body mass index (a), fruit and vegetable intake (b), and physical activity (c). *Significantly different (p < 0.05) compared with those who rated their health as excellent.
lower risk for NCDs, be more physically active, and consume more servings of fruits and vegetables per day than those based at worksites with fewer facilities. The main finding from this study was that employees at companies with a greater number of health promotion facilities were more likely to engage in healthy lifestyle behaviors, specifically meeting the physical activity guidelines and eating five or more
servings of fruits and vegetables per day. The relationship between facilities and behavior improved if the facility was specific to promoting an intended behavior. For example, the odds of employees meeting the physical activity guidelines were higher when comparing self-reported physical activity with the physical activity-related facilities and environment at the worksite. In addition, more employees were meeting the five servings of fruits and vegetables per day recommendation in those companies that had a greater number of nutrition-related health promotion programs. These findings are supported by the “North Carolina SixCounty Cardiovascular Health Survey,” in which employed adults were more likely to report being physically active if their worksites subsidized gym membership or if they were able to participate in physical activity during working hours.23 The odds of employees participating in physical activity during their leisure time were 4.1 (95% CI, 2.01; 8.40) times higher for employees whose worksites had at least three policies or programs that promoted physical activity.23 The odds of employees meeting the physical activity guidelines in this study were lower, and may be due, in part, to the different ways in which physical activity was quantified, or facilities scores were generated. We quantified physical activity as a continuous measure (on the basis of self-reported frequency, duration, and intensity of physical activity), and then categorized employees into those meeting or not meeting guidelines. Conversely, Lucove et al23 categorized physical activity as a dichotomous variable based simply on whether or not their participants reported any physical activity during their leisure or work time. Although the increased odds of 1.11 (P < 0.0002) of employees meeting the physical activity guidelines per additional facility observed in our research study might seem small, it is in line with what has been observed in previous research with worksite intervention studies.24 A review on worksite intervention studies found that interventions resulted in a median increase in physical activity of 11.1% per week, which ranged from 1.7% to 88.5%.24 This review also showed that the mean increase in fruit and vegetable intake was 0.14 fruit and vegetable servings per day with worksite interventions.24 Thus, our findings are within the ranges reported in previous studies.24,25 Furthermore, previous research has shown that return on investment can be achieved if employees’ risk is reduced by only 0.1% to 0.2% per year.26 Therefore, it seems that the health promotion programs and facilities at companies should be targeted at the specific behavior that needs to be addressed or improved. Employers that seek to encourage a particular behavior should consider developing facilities that specifically address those behaviors and not general health facilities. The most commonly reported physical activity program reported in this study was the provision of sports leagues for employees. Nevertheless, this type of program would probably only appeal to those employees who are already physically active, or have higher self-efficacy scores. Self-efficacy has been shown as an important predictor and mediator for participation in physical activity.27 Subsequently, employers should include other opportunities for physical activity that would appeal to the broader workforce. Another important finding from this research study was that certain self-reported healthy lifestyle behaviors, specifically physical activity and fruit and vegetable intake, are associated with selfreported health status. Despite the mean age of the employees being relatively young, there was a high prevalence of employees being overweight or obese, and an average of more than four risk factors per employee. Similar health and NCD risk profiles were observed in previous studies among South African employees.7 Most of the employees in this study were not meeting the US Centers for Disease Control and Prevention and American College of Sports Medicine’s guideline of 150 minutes of moderate-to-vigorous physical activity per week. Results from previous worksite-based research studies had
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TABLE 3. Worksite Facilities Scores for Physically Active (>150 min/wk) and Inactive Employees
Total facilities (out of 100) Physical activity facilities (out of 60) Physical activity environment (out of 20)
Total Mean (95% CI)
Physically Active Mean (95% CI)
Inactive Mean (95% CI)
Multilevel Model BO1; OR (95% CI)
58.4 (57.9–58.9) 35.8 (36.6–36.1) 11.1 (10.9–11.1)
59.6 (58.6–60.6) 37.9 (37.3–38.5) 11.9 (11.7–12.2)
58.1 (57.6–58.6) 35.2 (34.9–35.5) 10.8 (10.7–10.9)
−0.004; 0.99*a (0.9907–0.999)* −0.19; 0.83*a (0.74–0.93)* −0.18; 0.8*a (0.75–0.93)*
*P < 0.05. a The system modeled the probability of inactive. As such the signs of the regression coefficients are reversed and the odds ratios are inverted. CI, confidence interval; BO1, coefficient value from the Hierarchical linear model; OR, odds ratio.
and vegetable consumption were more likely to report their health status as good than those in the lower quartiles (odds ratio, 1.30; 95% CI, 1.11 to 1.53).32 Therefore, employees who perceived their health as good or excellent had reduced risk for NCDs.
Fruit and Vegetable Intake Nutrition Facility Score
7.0
Strengths and Limitations
6.5
6.0
*
is k R At
N
ot a
tR
is
k
To ta l
5.5
FIGURE 2. Nutrition facilities scores for the total group, according to fruit and vegetable intake: mean (95% CI). Represents significant differences (p < 0.05) between those ‘at risk’ compared with those ‘not at risk’. similar results, with low levels of physical activity ranging from 22% to 56% among employees.28,29 Therefore, large proportions of the employees are at increased risk of NCDs and would benefit from worksite health promotion programs. In this study, we found that self-reported health status was significantly associated with BMI, physical activity, and fruit and vegetable intake. The mean BMI was similar for employees who rated their health as fair, poor, and very poor. This might be due to a lack of understanding of what is regarded as an ideal body weight by South Africans.30 In a recent South African National Health and Nutrition Examination Survey, only a few respondents were able to identify a silhouette representing ideal body weight, compared with under- or overweight.30 Employees who perceived their health status as excellent or good were more physically active, ate a healthier diet composed of more fruits and vegetables, and had lower BMI measures than those who perceived their health as poor. Because of the current study being cross-sectional in nature, we are unable to determine whether the employees’ poor health status was a result of inactivity or being overweight. Nevertheless, the findings from this study are in line with other research.27,31,32 Bize and Plotnikoff33 reported comparable findings among employees participating in a worksite intervention program in Canada. The Canadian study also showed a statistically significant lower BMI and increased leisure time physical activity levels, with better self-reported health status.33 In addition, Pan et al31 found that men and women who reported their health as poor, fair, or good were less likely to meet physical activity recommendations than those who reported their health as excellent. Furthermore, men and women participating in the European Prospective Investigation into Cancer-Norfolk study with the highest fruit 1098
One of the main strengths of this research study is that the participants were from a range of worksites, representing a variety of sectors. In addition, both employer and employee completed the two sets of questionnaires independently of each other. As this is a cross-sectional study, we are unable to determine whether healthier people choose healthier worksites, or whether healthier worksites promote employee health. Thus, direction of causality cannot be determined on the basis of this study design. Nevertheless, the potential improvements in physical activity and fruit and vegetable intake, with the inclusion of facilities that promote these behaviors, are comparable to those observed in previous reviews of worksite intervention programs.24 Another limitation is related to participation bias where the companies that participated in the Discovery Healthy Company Index may have been more likely to be interested in benchmarking their worksite facilities programs and employee health than those of other companies. Previous research has shown that benchmarking health promotion practices in the worksite might be beneficial for those employers who wish to improve the efficacy of their programs and also to track changes over time.26 Similarly, the employees who volunteered to participate in the survey might have a better health status and lifestyle behaviors than those who did not participate, thus introducing some bias. Colkesen et al.34 reported that the employees who participated in an online health risk assessment were older, had a higher self-reported health status, and had fewer sick leave days per year than the nonparticipants. Nevertheless, there were no differences in sex, education level, and workability between the participants and nonparticipants. Therefore, the findings of this study might not be generalizable to the entire working population, but only to those who would choose to participate in a survey or health risk assessment.
SUMMARY There is a paucity of data providing evidence of the relationship between worksite cultures of health, which include programs and environmental initiatives supporting healthy behaviors, and employee health.26 The provision of worksite health promotion programs, together with self-reported health status, is significantly and positively associated with increased levels of physical activity and fruit and vegetable intake among South African employees participating in the Healthy Company Index. Although modest, these findings are encouraging and suggest the importance of creating worksite programs that promote healthy behaviors, which could play a role in improving employee health. Nevertheless, this is a crosssectional study and further research investigating the effectiveness of worksite health promotion programs is still required. Furthermore,
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cohort studies that employ a longitudinal study design will provide more insight into the role of the worksite environment and healthy lifestyle behaviors.
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